Multiple scaphoid bone cysts due to repetitive micro-fractures
Initially, the patient was treated with an EXOS splint to protect the scaphoid pending the MRI, which could not rule out fractures due to the multiple cysts within scaphoid. Therefore, a CT scan was secured, which also failed to rule out fractures. The patient was advised to avoid weight lifting and wear the EXOS splint until follow-up in four weeks. At follow-up, he reported decreased pain and was allowed to lift weights with the splint on but without directly loading the wrist joint. Upon re-evaluation two weeks later, the patientís symptoms persisted and his desired activity level was limited. After six weeks of conservative treatment featuring rest/modified activity and the EXOS splint, he was referred to an Orthopaedic Hand Surgeon, who elected to take the patient to the operating room. His operative findings and treatment included:
1. Left scaphoid intraosseous cysts; curettage and bone grafting of left scaphoid with distal radius autograft.
2. Left Palmer type 1B triangular fibrocartilage complex tear; debridement and repair.
3. Partial left scapholunate ligament tear; repaired arthroscopically.
4. Two left wrist intraarticular loose bodies at scapholunate interval; removed.
The patient had limited flexion and extension of the wrist at his four week post-operative visit. Therefore, he initiated occupational therapy three times per week for six weeks. At his twelve week follow-up visit, he had full, painless range of motion of the wrist. At 12 months, the patient remained free of pain and was able to continue his desired level of activity.
This case illustrates the need to call on surgical intervention when a patient fails non-operative management. In addition, the initial xrays demonstrated the cystic scaphoid, and MRI and CT did not further change this impression. Clinical course justified taking this patient to surgery, regardless of advanced imaging.
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